Pain, anxiety and patient satisfaction in office hysteroscopy, is there a link? Are patient satisfaction questionnaires reliable?


  • Antonio A. Paulo Department of Obstetrics and Gynecology, Hospital Centre Tondela, Viseu, Portugal Department of Health Sciences, University of Aveiro, Portugal
  • Antonio Pipa Department of Obstetrics and Gynecology, Hospital Centre Tondela, Viseu, Portugal
  • Claudia Raquel Andrade Department of Obstetrics and Gynecology, Hospital Centre Tondela, Viseu, Portugal
  • Raquel Oliveira Psychologue accompagnante, Cabinet ESPAS-IDDEES, Paris, France
  • Vera M. Afreixo Institute of Biomedicine, University of Aveiro, Portugal



Office hysteroscopy, Anxiety, Pain, Satisfaction questionnaires


Background: Office hysteroscopy is becoming increasingly popular leading to examinations and operations without anesthesia.  Anxiety is always present before an aversive medical intervention and may play a role in pain perception. The objectives of the study were to determine if pain perception is linked to anxiety and how well patient satisfaction questionnaires correlate with pain.

Methods: Prospective observational study enrolled one hundred and four women. One hundred cases were included and analyzed. Patients scheduled for office hysteroscopy, who accepted to participate and were able to answer questionnaires.

Results: A ten centimeter visual analogue scale was used for pain evaluation and the State anxiety-trait inventory for adults questionnaires for anxiety assessment. Three other satisfaction questionnaires, each consisting of three answers, were also administered and investigated. Analysis was performed using SPSS 22.0 IBM for windows software tools.

Conclusions: Correlation between anxiety and pain reporting showed no influence with anxiety trait (p value = 0.4170) and a mild correlation with anxiety state (p value = 0.146). Classification of pain into “no pain”, “mild pain”, “moderate pain” and “severe pain”, should be revised in office hysteroscopy: for visual analogue scale, scores of 2.5 to 3 cm correspond to the lower boundary of moderate pain and scores above limit 6.5 cm should define pain as severe. Satisfaction questionnaires significantly correlated to discomfort (p value <0.001) and may be a practical option to assess tolerance of medical procedures with excellent sensibility and specificity.


Campo R, Van Belle Y, Rombauts L, Brosens I, Gordts S. Office mini-hysteroscopy. Hum Reprod Update. 1999;5(1):73-81.

Fatemi HM, Kasius JC, Timmermans A, van Disseldorp J, Fauser BC, Devroey P. Prevalence of unsuspected uterine cavity abnormalities diagnosed by office hysteroscopy prior to in vitro fertilization. Hum Reprod. 2010;25(8):1959-65.

Ergenoglu M, Yeniel AO, Yildirim N, Akdemir A, Yucebilgin S. Recurrent uterine rupture after hysterescopic resection of the uterine septum. Int J Surg Case Rep. 2013;4(2):182-4.

Buchanan EM, Weinstein LC, Hillson C. Endometrial cancer. Am Fam Physician. 2009;80(10):1075-80.

Clark TJ, Barton PM, Coomarasamy A, Gupta JK, Khan KS. Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies. BJOG. 2006;113(5):502-10.

Van Dongen H, De Kroon CD, Van den Tillaart SA, Louwe LA, Trimbos-Kemper GC, Jansen FW. A randomised comparison of vaginoscopic office hysteroscopy and saline infusion sonography: a patient compliance study. BJOG. 2008;115(10):1232-7.

Guin G, Sandhu SK, Lele A, Khare S. Hysteroscopy in evaluation of abnormal uterine bleeding. J Obstet Gynaecol India. 2011;61(5):546-9.

Guruwadayarhalli B, Jones SE, Srinivasan V. Hysteroscopy in the diagnosis of postmenopausal bleeding. Menopause Int. 2007;13(3):132-4.

Lee DO, Jung MH, Kim HY. Prospective comparison of biopsy results from curettage and hysteroscopy in postmenopausal uterine bleeding. J Obstet Gynaecol Res. 2011;37(10):1423-6.

Pal L, Lapensee L, Toth TL, Isaacson KB. Comparison of office hysteroscopy, transvaginal ultrasonography and endometrial biopsy in evaluation of abnormal uterine bleeding. JSLS. 1997;1(2):125-30.

Garbin O, Kutnahorsky R, Gollner JL, Vayssiere C. Vaginoscopic versus conventional approaches to outpatient diagnostic hysteroscopy: a two-centre randomized prospective study. Hum Reprod. 2006;21(11):2996-3000.

Siristatidis C, Chrelias C, Salamalekis G, Kassanos D. Office hysteroscopy: current trends and potential applications: a critical review. Arch Gynecol Obstet. 2010;282(4):383-8.

Cooper NA, Smith P, Khan KS, Clark TJ. Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. BJOG. 2010;117(5):532-9.

Marteau TM, Walker P, Giles J, Smail M. Anxieties in women undergoing colposcopy. Br J Obstet Gynaecol. 1990;97(9):859-61.

Kola S, Walsh JC. Determinants of pre-procedural state anxiety and negative affect in first-time colposcopy patients: implications for intervention. Eur J Cancer Care (Engl). 2012;21(4):469-76.

Walsh JC, Curtis R, Mylotte M. Anxiety levels in women attending a colposcopy clinic: a randomised trial of an educational intervention using video colposcopy. Patient Educ Couns. 2004;55(2):247-51.

Sullivan MJ, Stanish W, Waite H, Sullivan M, Tripp DA. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Pain. 1998;77(3):253-60.

Baser E, Togrul C, Ozgu E, Esercan A, Caglar M, Gungor T. Effect of pre-procedural state-trait anxiety on pain perception and discomfort in women undergoing colposcopy for cervical cytological abnormalities. Asian Pac J Cancer Prev. 2013;14(7):4053-6.

Sullivan M. Gender Differences in Pain and Pain Behavior: The Role of Catastrophizing. Cognitive Therapy and Research. 2000;24(1):14.

Spielberger CD. STATE-TRAIT ANXIETY INVENTORY. In: Craighead IBWaWE, editor. The Corsini Encyclopedia of Psychology: John Wiley & Sons, Inc. 2009.

Julian LJ. Measures of anxiety: state-trait anxiety inventory (stai), beck anxiety inventory (bai), and hospital anxiety and depression scale-anxiety (hads-a). arthritis care res (Hoboken). 2011;63(11):S467-72.

Kvaal K, Laake K, Engedal K. Psychometric properties of the state part of the Spielberger State-Trait Anxiety Inventory (STAI) in geriatric patients. Int J Geriatr Psychiatry. 2001;16(10):980-6.

Rodrigues C. Validação do teste TSAI-Y de Spielberger: avaliação da ansiedade face aos testes. psicologiacompt. 2009.

Kokanali MK, Cavkaytar S, Guzel AI, Topcu HO, Eroglu E, Aksakal O. Impact of preprocedural anxiety levels on pain perception in patients undergoing office hysteroscopy. J Chin Med Assoc. 2014;77(9):477-81.

Carta G, Palermo P, Marinangeli F, Piroli A, Necozione S, De Lellis V. Waiting time and pain during office hysteroscopy. J Minim Invasive Gynecol. 2012;19(3):360-4.

Gupta JK, Clark TJ, More S. Pattison H. Patient anxiety and experiences associated with an outpatient one-stop, see and treat hysteroscopy clinic. Surg Endosc. 2004;18(7):1099-104.

Angioli R, De Cicco Nardone C, Plotti F, Cafa EV, Dugo N, Damiani P. Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial. J Minim Invasive Gynecol. 2014;21(3):454-9.

De Iaco P, Marabini A, Stefanetti M, Del Vecchio C, Bovicelli L. Acceptability and pain of outpatient hysteroscopy. J Am Assoc Gynecol Laparosc. 2000;7(1):71-5.

Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis. 1978;37(4):378-81.

Program VIHA EoL. principles of pain Assessment. 2008. Available from: NR/rdonlyres/FB1E3BDD-2D23-4C53-A4D3-0F9D2DCE1081/0/PrinciplesOfPainAssessment.pdf.

Toolkit SWRWC. WHO Pain Ladder with Pain Management Guidelines 2010. Available from:

Taddio A, O'Brien L, Ipp M, Stephens D, Goldbach M, Koren G. Reliability and validity of observer ratings of pain using the visual analog scale (VAS) in infants undergoing immunization injections. Pain. 2009;147(1-3):141-6.

Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK. Assessment of pain. Br J Anaesth. 2008;101(1):17-24.

Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003;4(7):407-14.

Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale Multidisciplinary Pain Inventory (WHYMPI). Arthritis & Rheumatism. 2003;49(S5):S96-S104.






Original Research Articles